Glass Houses

Here's some advice I have given teenage boys who are going toe-to-toe with their mothers about a health issue:
Don't go toe-to-toe with your mother; it's a no-win situation. Either you are right, and you are looked at as a "smarty-pants" or you are wrong, and have given her a huge "I told you so." If, on the other hand, you keep quiet and listen to what she's saying, it's a win-win: either she's right and you learn something, or she's wrong, and you have been vindicated.

Fathers often pipe in that this applies to wives as well. Mom's don't seem to disagree (for some mysterious reason).

While this may be sound relational advice, it also needs to be heeded by the medical community in its relationship to "complimentary and alternative medicine" or CAM. I am not saying we shouldn't be angry and frustrated with the CAM purveyors who are harming and even killing people (such as the anti-vaccine movement). I am not saying that we should embrace CAM and put it at anywhere near equal footing with our profession. What I am saying is that in our enthusiasm to win the argument, we can undermine our own credibility.

The typical argument against CAM and for traditional medicine goes like this:

Traditional medicine is based on science. This means that for something to be accepted, it must be tested by more than one study and shown to be valid. It also means that any treatment or test can and should be challenged in its validity. If it cannot stand up to scrutiny of thorough analysis, it shouldn't be accepted.

CAM, on the other hand, is largely based on anecdotal evidence. When something gets enough science behind it, the argument goes, the therapy or test moves from the realm of CAM to that of traditional medicine.

Therefore, by definition, traditional medicine must be more trustworthy than CAM, since only treatments on the traditional medicine side are supported by science.

I think there is much validity to this argument - and it is one that I have used when arguing this subject. But there is also a huge flaw in one of the assumptions. The flaw is in the very first statement in the argument: "Traditional medicine is based on science." While this is, in my opinion, a true statement, the inference from this statement, that all traditional medicine practiced is based on solid scientific evidence, is false. Very false. Some of the medicine I practice is based on science, and all of it is open to question, but not all of it. Much of what we do is based on very weak scientific evidence, some of it is even practiced in the face of contradicting data.

Here are some examples:

Fenofibrate - The drug Fenofibrate (Tricor, and others) is one of the most potent drugs to lower triglycerides. Type 2 diabetics are particularly prone to having high triglycerides, and so are often put on this medication. The elevation of triglycerides is of unclear significance (although very high levels do increase a person's risk of developing pancreatitis). To address this problem, the ACCORD trial was performed to assess (among other things) the efficacy of the drug to lower the rate of heart disease. After all, people don't die of triglycerides, they die from heart attacks. Here are the results (from NEJM):

Conclusions The combination of fenofibrate and simvastatin didnot reduce the rate of fatal cardiovascular events, nonfatalmyocardial infarction, or nonfatal stroke, as compared withsimvastatin alone. These results do not support the routineuse of combination therapy with fenofibrate and simvastatinto reduce cardiovascular risk in the majority of high-risk patientswith type 2 diabetes.

But this medication continues to be aggressively pushed and widely prescribed. When these results came out I expected to see the Tricor rep hanging her head, but instead she excitedly pointed out a sub-group analysis showed people on this medication had a lower risk of eye problems related to diabetes.

Colonoscopy - Clearly there is good evidence for colonoscopy, right? Gary Schwitzer discusses this in a letter to Harry Smith, who is campaigning in favor of colonoscopy:

Did you know that? Did you consider doing a live promotion of the stool blood test? Granted, it might have been a little gross, but we did see your colonoscopy. And it appears that this kind of colonoscopy promotion is what helped make it the most popular colon cancer screening test, despite the evidence (or lack thereof).

Antibiotics - What do sinus infections, ear infections, conjuctivitis, and bronchitis have in common? They all get better without antibiotics. Studies have shown clearly that sinusitis does not do better when treated with antibiotics, yet this prescription is commonly given. Ear infections are supposed to be treated with "watchful waiting," where the parent treats the pain and only uses antibiotics if it does not get better. The other two infections are 99% viral, so are not fixed at all with antibiotics. Still, all of them are treated with antibiotics with great frequency.

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Again, I am not saying that traditional medicine and CAM are equally valid. What I am saying is that we overstate the scientific basis for traditional medicine. It's not wrong to do things that aren't yet proven; often we end up using the best evidence available, which sometimes is sparse. But giving the perception that traditional medicine is scientifically "proven" (there is no such thing as scientific proof, just support), is only setting us up to look really stupid when what we do is contradicted by clinical data and give ammunition to those who support truly unproven therapies.

The very nature of the practice of medicine makes it something that uses science, but often is not itself scientific. Medical studies take a group of people and draw conclusions about certain interventions. Medical practice takes those studies and tries to find which one applies to the person sitting on the other side of the room. Often there are no studies, however, and we need to just do "what makes sense."

What's my point? We need to be careful in our attacks on CAM. We need to be sure we don't give the impression that everything we do is scientific. People will embrace other things because traditional medicine doesn't always work. We should not over-promote unproven things (see also: mammography and PSA testing) and we should also be aware of the commercial motivation behind a lot of these recommendations. To quote the researcher who "invented" PSA testing:

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

We are often operating on shaky ground. There is no solid ground a lot of times, but our saying it is not shaky doesn't make it so.